Chapter 4: Application of Echocardiographic Simulators in Training for Neonatal Echocardiography^*

INTRODUCTION

Echocardiography is the predominant noninvasive method of assessing cardiac structure and function. Although initially this technique resided exclusively in the domain of the cardiologist, more recently it has been increasingly utilized for point-of-care applications across different specialties.¹ The utility of point-of-care echocardiography has been demonstrated by neonatologists in the neonatal intensive care unit,² anesthesiologists during the perioperative period,³ intensivists in the critical care setting,⁴ and emergency medicine physicians in the emergency care setting.⁵ The development of more advanced and portable systems has facilitated this change. However, the widespread use of point-of-care echocardiography, especially for neonatal intensive care, has been hampered by the lack of adequately trained non-cardiology specialists and access to patients.

Training in neonatal point-of-care echocardiography (also known as “targeted” or “functional” echocardiography) is a complex process that requires not only comprehensive theoretical knowledge but also extensive hands-on training to acquire the all-important technical skills. At present, there is no alternative method for achieving technical competence in neonatal echocardiography other than performing studies on actual neonates. However, because of the restricted access to live subjects, particularly neonates, opportunities for practical training are limited. To overcome this obstacle, echocardiography simulators have been developed. Weidenbach et al⁶ introduced two-dimensional (2D) echocardiography simulation by the use of real three-dimensional (3D) image volumes, which have been used both for transthoracic and transesophageal echocardiography.⁷ In infants and younger children, simulators based on real 3D volumes have been used for training physicians with minimal echocardiography experience with good results. The knowledge of cardiac anatomy as depicted by echocardiography and detection of congenital heart defects is improved, while spatial orientation and hand-eye coordination is enhanced by the use of the simulators.^8–10 However, presently available transthoracic echocardiographic simulators based on real 3D volumes are restricted to 2D echocardiography, which lacks other modalities such as color flow Doppler, spectral Doppler, and M-mode. Furthermore, since image volumes are obtained either from subcostal or apical windows, simulation of echocardiography from parasternal and suprasternal windows may be suboptimal. In general, real transthoracic echocardiographic images obtained in older children and adults are of poor quality and are not suitable for simulation. For these reasons, for transthoracic echocardiography, almost all commercially available simulators obtain their 3D images from other imaging platforms such as MRI and render them to look like echocardiograms. These simulators are used extensively in training intensivists, emergency room physicians, and anesthesiologists, as well as cardiology technologists and trainees.

ECHOCOM TRAINING SIMULATOR

Recently, Weidenbach et al have introduced a training simulator for echocardiography in neonates.¹¹ Although this simulator includes extensive cases of congenital cardiac defects, along with cases of functional and acquired heart diseases, it only simulates 2D echocardiography for anatomical diagnosis and has the above limitations. In spite of these limitations, it is used by neonatologists ...